Enhancement should be contextualized to include the collective impact of existing and potential enhancements. A macro, upstream policy or organization to consider the impact in context is important. Various administrations have had special councils (Presidential Commission and the older Presidential Council on Bioethics) considered cloning, stem cell research, and some enhancements. Special commissions in the executive branch may not have the wherewithal to handle incremental changes, considering each new technology and its impact. The FDA, as the ground level approval body, is not specifically tasked with contextualizing and considering the implications beyond safety and efficacy. Because there is not a clear line on what falls within enhancement and many technologies or medicines can be used to treat or to enhance, the Commissions can lead to sweeping acceptance or rejection (or occasionally compromise) and the FDA could approve something safe and effective without enough context.
This is not a simple debate between “transhumanists” and bio-conservatives. Enhancement calls for critical analysis of the reasoning of both sides. In the middle ground, more ethical issues abound and the ability to achieve the desired effect is greater. A framework to navigate enhancements must begin by distinguishing treatment of a medical condition from enhancement. The nature of the controversy arose because medicine and science somewhat encroached naturally on bodily manipulations beyond the curative or therapeutic. Enhancements give an advantage and to many seem outside the ethos of medicine.
“Enhancement, here defined as choosing the physical (but not explicitly medical) traits like height, strength, intellect, memory, or talent, touches on the essence of what societal values should be protected and who should be part of the decisions to allow or prohibit enhancements.” (Zimmerman, Opting Out, publication pending) Enhancement tends to include augmentation that moves someone from the normal range to beyond normal for humans. There are many enhancements currently in use. Some have enhancement as the innovative goal, like Botox for cosmetics and steroids for athletic improvement. Other innovations have an enhancing side effect. (I love the metal plate and screws in my wrist which is probably stronger than my other wrist and possibly above the status quo for my age if compared to natural bone strength, but I got the treatment which happened to enhance after breaking a bunch of bones.) Medicine is not always able to target or define “normal’, something that is normative itself.
What is the ethical difference between new technologies inside the body versus those outside the body? What if an Apple watch measuring our steps were implanted under the skin? The ability to Google something could replace broader memorization skills without touching the human body. The enhanced ability to look up something forgotten when it is an outside-the-body tool is well accepted. Vagus nerve stimulators (an epilepsy implant) and pacemakers are both designed to bring people to a normal status quo. Their capabilities if used differently or at older ages would push beyond the human status quo. If contact lenses were improved to provide super distance vision and acted like multi-focal existing lenses as well, would that be ethically different from a new twist on Lasik that accomplishes a super distance vision (I mean well beyond 20-20)?
CRISPR made gene editing affordable and faster. Medicines also can target genes, activating and deactivating them, blocking receptors, and changing their expression. There is opposition to embryonic changes that would be hereditary. Some of those changes, if targeting those with known genetic diseases, would have a result similar to a preimplantation genetic diagnosis. By manipulating the gene line in embryos, diseases could be eliminated if the use were universal, something unlikely. The Chinese experiment to produce HIV resistant embryos was met with dismay, but HIV medications are heralded as welcome scientific feats.
There would be an ethical difference in targeting those with an illness (propelling the risks of the gene editing onto at-risk embryos versus an embryo without elevated risk). In the He Jiankui controversy, where allegedly two births with an edited CCR5 gene occurred, the alleged gene editing also could have had ancillary implications related to intelligence. The original Chinese HIV embryonic experiments did not really work (four out of 263 embryos were changed). I find the issue of informed consent (the bar for consent to research that is not therapeutic is higher and this was not therapeutic as the genetic material did not have HIV) and the issue of justice beside the point.
Discussions about the sanctity of the human genome fail as drugs and other alterations or choices (like in PGD) are so well-accepted. Even nutrition can change the expression of genes. Moving forward, separating the issues of humanness, diversity, and fragility from “sanctity” is helpful as it reflects the many ways genes and genetic expression already are manipulated. Sanctity arguments may attract accusations of hypocrisy.
Whether disease resistance should fall within enhancement should depend on the normal human status quo. If fragility were a special circumstance, below the status quo, the change would not be seen as enhancement. I assert that this type of disease-proofing is not ethical both because it poses unknown risks (presumably science will improve), because it fails to target a specifically at-risk population (too broad if used at the societal level), targeted versions may become feasible (for now, when genes are identified that make people have a special susceptibility, then PGD already avoids the embryos with a genetic mutation), and the public should have a voice in the role of human fragility in defining humanness. The safety and efficacy issues will likely be resolved making the issues surrounding quality of life, what makes life special, and incorporation of diverse views the big picture ethical issues. Rather than using embryonic germline enhancement, discarding embryos with a mutation and implanting those without is a solution many choose.
A focus on the use of CRISPR in ways that effect gene expression but are not inheritable is more realistic for now. Many interventions are likely not inherently unethical or ethical. The increasing therapeutic use currently in play concerns reprogramming somatic cells to fight disease, not enhancement.
Germline changes and cloning should be evaluated under a framework that considers the future of humanity. Instead of stretching the word justice and applying the typical autonomy arguments, when technology affects future generations as well as those pursuing the technology to make a genetic enhancement (even a nonhereditary one), an inclusive analysis is needed.
Use-Based Regulations: Is the enhancement “radical”
The focus should be on the use of the intervention rather than the intervention itself. (That it changes a gene is understood but who would use it for what purpose should drive the analysis and the regulatory approval structure.) The broader implications of the intervention (what it could mean for society) must consider the implications for the enhanced and those unenhanced. Societal enhancement happens slowly through each small invention. A regulatory framework that approves of certain medications for certain uses is in place but is not the right body to expand to some new developments. In medications, we see off-label use is predominant and often beneficial. Each use of a procedure that could potentially enhance should be contextualized. Adderall and Ritalin differ in depth and scope from neurosurgery or gene editing, yet used inappropriately may cause personal and societal problems as well. The societal acceptance (and legal prescribing) of them despite the downsides of their use are not enough to justify societal acceptance of other (including germline) enhancements.
Justice is Not the Crux of the Issue
There are many causes of the development of social classes and there is an apparent lack of political will to decrease socioeconomic inequality. To me, germline editing certainly could exacerbate injustices but, much more importantly, it can change humanity as we know it. Relying on justice alone would open the floodgates if the enhancement became cheap and accessible to everyone. There would be no further ethical safety net. There is a big picture concern, yet justice (as seen in principlism) seems to limit constructive approaches.
A justice framework can result in a failure to define what we collectively value about humanness. (An analogous line of reasoning is in the Hayry article: arguments against incest that are based solely on potential genetic abnormalities miss the ethical point.) Justice as a vocabulary word does not do enough for what could go wrong. That is, if the sea change to humanity were done in a just way (whether everyone had equal opportunity, or the entire population was enhanced in the same way to the same degree), bioethical frameworks still must require more reasoning to support it. Certainly, the view that full-on population enhancement is likely a bad outcome goes well beyond justice.
Enhancement poses risks to compassion (if everyone could choose to enhance, there may be less compassion for those who do not or are comparatively less-abled) and risk to competition or appreciation of a talent or intellect (if you can buy the enhancement, it would not speak to practice or effort although arguably being born with a special trait is not a reflection of dedication either). Those considerations speak to humanity and why people value diversity of health, intellect, talent, and strength in deeper ways than reflected in the literature.
Efforts to “disease-proof” by diet and lifestyle have known effects on outcome. The role of science in quick fixes could foster less responsibility in self-care. The comparison of ways to achieve outcomes should include healthy diet and lifestyle, and the use of and improved access to known treatments. Scientists compete for the same research money, something reflecting political will and budgets. Resources directed to food and lifestyle could have reduced the COVID-19 death toll based on data about comorbidities. Would research to design babies to be resistant to all coronaviruses be better or worse? Should science get more total research dollars and explore both?
When a germline is not involved, autonomy interests and rights could support access to enhancement. Constitutionally guaranteed liberty interests are unclear in the arena of enhancement, where new state interests could develop.
The stakeholders with a say in defining what makes humanity special should be broad. Regulating germline enhancements in deliberative democracy requires participation of voters. Traditions, religious beliefs, and cultural views that celebrate regular people could be marginalized by an enhanced population, even if the enhancement reflects justice. Furthermore, the distribution of work would become fraught with problems if enhancement elevated everyone intellectually or with physical strength. In enhancement, not everyone has an equal stake. To assign some people to represent future society (maybe philosophers and sociologists) is difficult. In the scientific arena, often the scientists are self-policing and the reasoning is already relegated to one side of the equation. The philosophers and sociologists could be alarmist as seen in the paper below by members of the Presidential Commission.
Hypothetically, what if there were an infertility pandemic and enhancement becomes part of the solution to infertility problems, i.e., if a stronger zygote (or blastocyst) were the only way to create babies at all, and the alteration had an ancillary effect of a computer-like brain or excessive height?
In the diminishment arena, the question of improving life by taking away or limiting a capacity also impacts the theoretical issue of how to define enhancement. If ignorance is bliss, then diminished intellect becomes an enhancement. See Earp and Savulescu below.
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David Masci, “Human Enhancement: The Scientific and Ethical Dimensions of Striving for Perfection,” Pew Research Center, Science and Society, July 26, 2016 https://www.pewresearch.org/science/2016/07/26/human-enhancement-the-scientific-and-ethical-dimensions-of-striving-for-perfection/
Twine, R., “Constructing Critical Bioethics by Deconstructing Culture/nature Dualism.” Med Health Care Philos 8, 285–295 (2005). https://pubmed.ncbi.nlm.nih.gov/16283491/
Huxley, J. “Transhumanism”. Ethics in Progress, Vol. 6, no. 1, Feb. 2015, pp. 12-16. https://pressto.amu.edu.pl/index.php/eip/article/view/9303(Basic article pro transhumanism; seems to favor radical …)
Anita L. Allen, Nicolle K. Strand, “Cognitive Enhancement and Beyond: Recommendations from the Bioethics Commission,” Trends in Cognitive Science, Volume 19, Issue 10, October 2015, Pages 549-551 https://doi.org/10.1016/j.tics.2015.08.001 (paper comments that media hype creates concerns and provides the Commission’s recommendations focused more on prioritizing therapeutic innovation and use. The author’s concern for justice in the realm of “safe and beneficial” enhancements drowns out some of the other concerns, especially surrounding how to define beneficial. For example, a use of CRISPR to cure Alzheimer’s is medical and, to me, not enhancement, yet some could argue the status quo in certain age group includes weak memory. The author’s also mix medical treatment with enhancement making an unclear distinction.)
HÄYRY, M. (2019). Justice and the possibility of good moralism in bioethics: CQ. Cambridge Quarterly of Healthcare Ethics, 28(2), 236-263. (Awaiting permissions) https://pubmed.ncbi.nlm.nih.gov/31113512/
Earp Brian, Sandberg Anders, Kahane Guy, Savulescu Julian, “When is diminishment a form of enhancement? Rethinking the enhancement debate in biomedical ethics,” Frontiers in Systems Neuroscience, Vol. 8 2014 https://www.frontiersin.org/articles/10.3389/fnsys.2014.00012/full (Article explores potential values of diminishment–making a trait worse, e.g. worsening memory or concentration, or capacity to love, Argues that while diminishment seems wrong under a functional-augmentation framework, under a goal-oriented reasoning, the authors assert the overarching goal, generally a better life, is the relevant framework. In that analysis, they broaden the definition of neuroenhancement beyond enhancing specific capacity to enhancing life.) (To me, an argument that a vasectomy is enhancement falls within their logic and represents a fact pattern that already operates under their assumptions.)
Reynolds, Joel Michael, “Health for Whom? Bioethics and the Challenge of Justice for Genomic Medicine,” Hastings Center Report, June 29, 2020. https://onlinelibrary.wiley.com/doi/full/10.1002/hast.1149(Views justice as “lifeblood” of medicine. This Hastings Center Special Report has 5 essays.)
Colin Koopman, “Coding the Self: The Infopolitics and Biopolitics of Genetic Sciences,” Hastings Center Report, June 29, 2020. https://onlinelibrary.wiley.com/doi/full/10.1002/hast.1150 (Abstract:
“The three analytical approaches are referred to as the state‐politics model, the biopolitical model, and the infopolitical model. Each of these models is valuable for different purposes. In terms of their influence in contemporary discussions, the first is by far the dominant approach, the second is gaining in importance, and the third is almost entirely neglected.” The article challenges assumptions in conceptual frameworks and highlights broader methods of analyzing bioethical issues.)
Nam, Jeesoo, “Biomedical Enhancements as Justice,” Bioethics, September 30, 2013 https://doi.org/10.1111/bioe.12061 (article uses social justice to justify a moral obligation to enhance. I find this pushes justice too far and exemplifies some limits of justice and the four principles approach.)
Robert Klitzman, Designing Babies, Designing Babies: How Technology is Changing the Ways We Create Children, New York: Oxford University Press, 2020. Link to Oxford Press
Older Cloning Articles:
Talbot, Margaret. The Cloning Mission; a Desire to Duplicate. New York Times. Feb. 4, 2001 https://www.nytimes.com/2001/02/04/magazine/the-cloning-mission-a-desire-to-duplicate.html
The Ethics of Cloning-to-Produce-Children. President’s Council on Bioethics. 2002. https://bioethicsarchive.georgetown.edu/pcbe/reports/cloningreport/children.html
Steinbock, Bonnie. Reproductive Cloning: Another Look (2006) University of Chicago Legal Forum: Vol. 2006, Art. 4. 111. https://chicagounbound.uchicago.edu/cgi/viewcontent.cgi?article=1388&context=uclf
Brock, Dan W. Cloning Human Beings: An assessment of the ethical issues, pros and con. Report and Recommendations of the National Bioethics Advisory Commission. (1997). https://govinfo.library.unt.edu/nbac/pubs/cloning2/cc5.pdf
Robertson, John A. Children of Choice: Freedom and the new reproductive technologies. (1996) Princeton University Press. Procreative Liberty. Chapter 2. https://journals.sagepub.com/doi/abs/10.1177/027046769501500127
Robertson, John A., Two Models of Human Cloning. 27 Hofstra L Rev 618 (1999). https://scholarlycommons.law.hofstra.edu/hlr/vol27/iss3/10/
The Witherspoon Council on Ethics and the Integrity of Science. The Threat of Human Cloning: Ethics, Recent Developments and the Case for Action. New Atlantis. Summer, 2015. https://www.thenewatlantis.com/publications/the-threat-of-human-cloning